英文病例表達(dá)模板

胸痛的英文病例(bìnglì)表達(dá)

Interviewthepatientswithchestpain第一頁，共十七頁。ContentHistorytakingPhysicalexaminationPatientnotewriting第二頁，共十七頁。IntroductionHowcanIhelpyoutoday?Whatbroughtyoutothehospital/clinictoday?Whatareyourconcerns?第三頁，共十七頁。ChestpainOnset開始時間Precipitatingfactors誘因Duration持續(xù)時間Relievingfactors緩解因素Frequency發(fā)作頻率Associatedsymptoms伴隨(bànsuí)病癥Previousepisodes既往發(fā)作Progression進(jìn)展第四頁，共十七頁。InterviewapatientwithchestpainHello,Mr.Jones,IamDr.Zhuang,it’snicetomeetyou.HowcanIhelpyoutoday?Doyouhavepain?Whendiditstart?Howlonghaveyouhadthispain?Howoftendoesitcomeon?Wheredoyoufeelthepain?Canyoushowmeexactlywhereitis?Doesthepaintravelanywhere?第五頁，共十七頁。

Whatisthepainlike,canyoudescribeitforme?Isitsharp,dull,burning,pulsating,cramping,orpressure-like?Isitconstant,ordoesitcomeandgo?Onascaleof1to10,with10beingtheworstpainofyourlife,howwouldyourateyourpain?Whatbringsthepainon？Doesanythingmakethepainbetter?Doesanythingmakeitworse?Haveyouhadsimilarpainbefore?第六頁，共十七頁。Associatedsymptoms:Nausea惡心

Vomiting嘔吐Cough,phlegm咳嗽，咳痰Shortnessofbreath呼吸困難Headache頭疼(tóuténg)Dizziness,roomspinningaroundyou,light-headed眩暈Passout,blackout,loseconsciousness,syncope暈厥Heartspeeding,palpitation心慌第七頁，共十七頁。Briefphysicalexam:

whattosaybeforeandduringtheexamIneedtolistentoyourheart/lungsnowCanyouholdyourbreath,please?Canyoutakeadeepbreathforme,please?Canyousit,please?Canyouturntoyourleftside,please?Iamgoingtoexamineyourlegstocheckfluidretention,isthatokaywithyou?Ineedtocheckthepulseinyourarmandlegsnow第八頁，共十七頁。PatientnoteVS:vitalsignsWNL:withinnormallimitsChest:nontender,lungscleartoA&P(auscultationandpercussion),Auscultation:decreasedbreathsounds[L/R]Abnormalsounds:wheeze,rub,rale[L/R][base/midlung/apex]第九頁，共十七頁。

CV:cardiovascularS1,S2WNLRegularrate&rhythm,RRRNorub/gallops/murmursittingandsupine(noRGM)NoJVD(jugularvenousdistention)PMInotdisplaced(pointofmaximalimpulse)Noclubbing,edemaCarotid,radial,DP(dorsipedis),pulseNL&equalB/Labsent/decreased/NL/boundingNocarotidbruits第十頁，共十七頁。Case

JosephShort,a46-year-oldmale,comestoEDcomplainingofchestpain第十一頁，共十七頁。HPI:Historyofpresentillness46yoMc/ochestpain.Thepainstarted40minutesbeforehepresentedtoEDwithasteady7/10pressuresensationinthemiddleofhischestthatradiatedtotheleftarmandtheneck.Nothingmakesitworseorbetter.Nausea,sweatinganddyspneaarealsopresent.Similarepisodeshaveoccurredduringthepast3months.Theseepisodeswereprecipitatedbywalkingupthestairs,strenuousworkandheavymeals.Painduringtheseepisodeswaslesssevere,lasted5-10minutes,anddisappearedspontaneouslyoraftertakingantacids.第十二頁，共十七頁。PhysicalexaminationPatientisinseverepainBP165/85mmHg(botharms)RR22/minuteNeck:noJVD,nobruits.Chest:Notenderness,clearsymmetricbreathsoundsbilaterally.Heart:PMInotdisplaced;RRR;normalS1/S2;nomurmurs,rub,orgallops.Abdomen:Soft,nondistended,nontender,⊕BS,nohepatosplenomegaly.Extremities:Noedema,peripheralpulses2+andsymmetric

第十三頁，共十七頁。DifferentialdiagnosisAcutecoronarysyndromeGERDAorticdissectionPericarditisPulmonaryembolismPneumothorax第十四頁，共十七頁。DiagnosticworkupECGCardiacenzymes(CK-MB,troponin)CXRchestX-rayTransthoracicechocardiogramCardiaccatheterizationCT—chestwithIVcontrast第十五頁，共十七頁。Thankyou!第十六頁，共十七頁。內(nèi)容